Where medicine gets hung up
Pandemic exposed American medical system’s inadequacies and inefficiencies, but could spur it to become less expensive, more efficient and more effective
If there is a silver lining to the devastation wrought by the pandemic, it likely lies in the glaring inadequacies and inefficiencies it exposed that are inherent in traditional American medicine. At the same time, it suggests ways to improve medical practice that can ultimately give us more bang for our health care buck.
Dr. Robert Steinbrook, an editor at JAMA Internal Medicine, said in an interview, “The pandemic exposed serious vulnerabilities in our health care and created opportunities to solve problems for the long term.”
Although the pandemic prompted many people to miss or delay medical care that sometimes resulted in more serious disease and more costly treatment, it also suggested steps American medicine can take to become less expensive, more efficient and more effective at protecting people’s health.
Exhibit No. 1: Half a century of evidence has documented the health-saving, lifesaving and cost-saving benefits of preventive medicine, yet this country has retained a chaotic, penny-wise-andpound-foolish medical system that often puts the treatment cart before the health-promoting horse.
As many experts have told me during decades of medical reporting, we really don’t have health care in this country; we have sickness care. We’re not getting more, we’re simply paying more. The United States spends 25% more per person on medical care than any other highly developed country and gets less benefit from it. And the care we get leaves us shamefully behind other developed countries in important health metrics, like maternal and infant mortality and healthy longevity.
“Our system is set up to produce a lot of health care but not necessarily a lot of health,” said Dr. Amol Navathe, a health economist at the University of Pennsylvania.
Even the routine annual “wellness visits” covered by Medicare are of minimal value for healthy adults and often result in a cascade of follow-up tests that yield little but cost plenty.
Dr. William Shrank of Humana, a national health insurance company, and lead author of a report on waste in the current health care system, said, “We’ve just been through a natural experiment that we can learn from.” Our yearlong battle with a deadly virus suggests ways to improve how medicine is practiced and utilized in the United States to foster better health for its inhabitants.
One of the most dramatic examples was the abrupt substitution of telemedicine for in-person visits to the doctor’s office. Although telemedicine technology is decadesold, the pandemic demonstrated how convenient and effective it can be for many routine medical problems, Navathe said.
Telemedicine is more efficient and often just as effective as an office visit. It saves time and effort for patients, especially those with limited mobility or who live in remote places. It lowers administrative costs for doctors and leaves more room in office schedules for patients whose care requires in-person visits.
Even more important, the pandemic could force a reckoning with the environmental and behavioral issues that result increasingly in prominent health risks in this country. We need to stop blaming genetics for every ailment and focus more on preventable causes of poor health like a bad diet and inactivity.
Consider the health status of those who have been most vulnerable to sickness and death from COVID-19. Aside from advanced age, about which we can do nothing, it has been people with conditions that are often largely preventable: obesity, Type 2 diabetes, high blood pressure, coronary artery disease and smoking.
Yet most physicians are unable to influence the behaviors that foster these health-robbing conditions.
“Many people need help to make better choices for themselves,” Navathe said. But the professionals who could be most helpful, like dietitians, physical trainers and behavioral counselors, are rarely covered by health insurance. The time is long overdue for Medicare and Medicaid, along with private insurers, to broaden their coverage, which can save both health and money in the long run.
Policy wonks should also pay more attention to environmental risks to health. Too many Americans live in areas where healthful food is limited and prohibitively expensive and where the built environment offers little or no opportunity to exercise safely.
Individuals, too, have a role to play. The pandemic has fostered “an opportunity for patients to take on a more active role in their care,” Shrank said in an interview.
Pandemic-based limitations gave prospective patients a chance to consider what procedures they really needed. Most elective surgeries were put on hold when hospitals and medical personnel were overwhelmed with the challenges of caring for a tsunami of patients infected with the virus.
Shrank suggested that people ask themselves, “How did you do without the procedure?” Maybe you didn’t really need it, at least not now. Maybe instead of costly surgery for a bad back or bum knee, physical therapy, home exercises or self-administered topical remedies could provide enough relief to permit desired activities.
Does every ache and pain require a doctor visit? Short of a catastrophic sign like crushing chest pain or unexplained bleeding, my approach is to wait a week or two to see if a new symptom resolves without medical intervention. I awoke one January morning with intense pain in my right wrist and forearm. Ice didn’t help, but I applied an anti-inflammatory ointment, took two naproxen, wrapped my wrist in a brace from the local pharmacy and refrained from crocheting for two days, by which time the pain had resolved.
When professional health care is needed, new approaches have become more acceptable during the pandemic, Shrank said. Emergency department visits and hospital admissions declined precipitously. Noting that many patients can be treated effectively at home by a visiting nurse, Shrank said, “No one wants to go to the hospital or a rehab facility if there’s a good alternative.”
Hartford Courant | Section 4 | Sunday, February 21, 2021
Dear Cathy: My cat, Crystal, is a blue point Siamese, about 6 years old. She doesn’t — and never has had — front teeth. So, she eats on her side teeth, which looks incredibly awkward. She drops food continuously, makes an incredible mess and makes snorts and funny sounds when eating. Her breath is quite bad when she yawns. Should I take her to see a vet about this, or is it just the way she eats? She is slender, but not skinny.
— Kari, Cold Lake, Alberta, Canada
Dear Kari: What you describe is perfectly normal for a cat with no front teeth. If those teeth are missing, it can be quite a struggle for a cat to keep food in their mouth when they chew.
There is nothing to be done about her missing teeth or eating style. If she has bad breath, however, a veterinarian should check on Crystal’s oral health to make sure she doesn’t have an issue and is not in pain. If your vet feels Crystal is too thin, then they can prescribe a higher caloric diet to ensure she is getting proper nourishment from her meals.
If all is well, then, congratulations, you just have a funny, messy eater on your hands.
Dear Cathy: I read about the senior who couldn’t adopt a pet because of her age. I live in South Florida and have tried for a year to adopt an adult dog. I filled out an application and was asked for my driver’s license. My birth date is on it. Rejection quickly followed.
I am 81, walk several miles every morning, attend water aerobics daily and, due to COVID-19, have stopped traveling. I have no plans to continue traveling
as I do not feel this pandemic will be under control for years to come. I manage my own financial affairs and am perfectly able to give a rescue dog a wonderful home. I live in a house with grass and trees, neighbors who walk small dogs and friends willing to assist, should I ever need help.
With this in mind, I can’t even get a home visit, let alone a visit inside the kennels to look at dogs. I was told by one rescue that I cannot request any breed of dog, even if available. I have wanted a schnauzer or schnauzer
mix. I had one for 16 years. One of the rescue organizations I spoke with said, “You take what I give you.” I have a neighbor who has been volunteering for our local shelter for 14 years. She is now in her 70s. She was rejected from adopting any dog from there. Her dog had just died. She ultimately bought a puppy from a pet store. She’s not the only one I know of that has done this.
I’ll end by saying if you ever come across an adult, housebroken miniature schnauzer or schnauzer mix looking for a good
home on the east coast of South Florida, please let me know.
— Ruth, Boca Raton, Florida
Dear Ruth: I have gotten so many letters from people who are upset that this woman was not allowed to adopt a dog because of her age, and rightly so. People should not be discriminated against and kept from adopting because of their age. I have been friends with a 99-year-old woman for 17 years. Imagine if she had been denied the companionship of a pet because she was 82 years old at the time of adoption.
Last I checked, anyone at any time can die or become incapacitated.
I know animal shelters and rescue groups want to ensure an animal has a forever home. But think of all the dogs and cats who need homes and all the retired people who have time to give.
Most animal shelters and rescue groups have a clause in their adoption contracts that say an animal must be returned to them if the adopter can no longer provide a home for the pet. That’s because they consider the lifetime welfare of that pet as their responsibility. So, why don’t they just agree to take the pet back if something unforeseen happens? That’s what they would do if it were anyone else.
You sound like the perfect adopter. This nonsensical discrimination must stop.
As the pandemic drags on, children and teenagers endure an unprecedented realignment of daily life.
Isolated in apartments and houses, kids contend with unending pressures — lost contact with friends and normal school life, grown-ups’ ubiquity and unwanted attentions, as well as the fear that their futures may be compromised by an invisible, deadly menace.
To help, concerned parents seek child and adolescent psychiatrists and psychologists, along with other counselors. But there aren’t enough such professionals to begin with in America, some experts say. And many of those are being inundated by young patients in need.
“Even before the pandemic, there was significant lack of access to child mental health care,” said Alex Strauss, a Marlton, New Jersey, psychiatrist who treats children, adolescents and adults. Lately, Strauss said, he’s received a 20% increase in calls from people asking for his help with “pandemicrelated difficulties.” He added, “With need growing, it can be almost impossible to see someone now. There’s a severe national shortage of therapists.”
Gail Karafin, a Doylestown, Pennsylvania, psychologist in independent practice, as well as a certified school psychologist, agreed. “I shudder when I have to make a psychiatric referral for a child, because it could be a long wait,” she said. “It’s a case of supply and demand, made more difficult by the pandemic.”
Beyond that, many psychiatrists, who are
medical doctors able to prescribe drugs, don’t take insurance, limiting therapeutic access for many families.
The mother of an eighth grade boy said she felt lucky to find a child psychologist after a month of looking. Her name, like those of other parents in this article, was withheld so she could speak openly about private family matters.
“I’ve gone through a high-conflict divorce,” the woman said. “And with COVID stress, I was trying to find someone to offer my son support, but it’s been difficult. A lot said they weren’t taking new patients.
“It’s like the help is there at arm’s length, but you can’t have it. When I think about families in more crisis than mine, that’s a frightening thought.”
Throughout America, there are an estimated 15 million children and
adolescents in need of therapy from mental health professionals, according to Jeffrey Geller, president of the American Psychiatric Association.
Yet, he added, there are just 8,000 to 9,000 psychiatrists treating children and teenagers in the U.S.
“We need 30,000, not 8,000,” noted Jodi Brown, a child and adolescent psychiatrist in Bryn Mawr, Pennsylvania. “Even kids who haven’t had psychiatric conditions are needing help to get through this.”
There are an estimated 38,000 to 40,000 school psychologists across the country, said Katherine Cowan, spokeswoman for the National Association of School Psychologists. Ideally, the child-to-practitioner ratio should be 500 students for every school psychologist, Cowan said. But the current configuration is 1,400 to one.
Among psychologists,
just 4,000 out of a total of 102,000 nationwide (around 4%), are clinical child and adolescent practitioners, according to data provided by the American Psychological Association.
“Parents are getting desperate to get their kids the help they need as the pandemic exacerbates the situation,” Cowan said. “Everybody is wearing thin.”
Unable to find or afford behavioral-health solutions, many parents are rushing their kids to hospital emergency rooms.
Between March and October 2020, the number of visits to emergency departments nationwide by children younger than 18 for mental health reasons increased by 44% over the same period in 2019, according to the Centers for Disease Control. The number of mental health visits for adolescents ages 12 to 17 was 31% higher; for children ages 5 to 11, it was up 24%, CDC figures show.
The ER trips are indication of parental desperation, say behavioral health professionals.
“The country is traumatized, and the ones being hurt most are children, whose neurological development is being affected after 10 months and counting of house arrest,” said Lise Van Susteren, a Washington, D.C., psychiatrist.
The difficulties families face are on display in the Philadelphia home of the parents of an 11-year-old boy diagnosed with attention deficit hyperactivity disorder (ADHD).
“For him, his problem wasn’t just getting used to going to school at home,” the boy’s father said. “It was putting our house in turmoil.”
It took six weeks to find a suitable psychologist covered by the parents’ insurance, he said. But the pandemic loaded the practitioner with many patients, the boy’s mother said. After the boy’s initial virtual appointment, the psychologist couldn’t see him again for two months.
Eventually, the boy was able to get more regular sessions, but then he needed the specialized help of a New York psychiatrist once a month. The doctor is an out-of-network provider who charges $425 an hour.
Many psychiatrists don’t accept patient insurance plans because the reimbursements aren’t enough, and the paperwork is prodigious, said Russell Holstein, a psychologist in Long Branch, Monmouth County, New Jersey. Quite a few psychologists don’t take insurance plans, either, other experts said.
That makes their services financially out of reach for many parents looking for help for their children.
Some patient advocates complain that insurance plans don’t offer enough choices for mental health services to begin with, worsening the problem of therapist availability.
On top of that, said
Shana Schwartz, a licensed clinical social worker in Ardmore, Pennsylvania, quite a few practitioners are parents themselves and are precluded from taking on new cases because they need to spend time with their own children who are out of school and unsupervised.
Often, to give parents options, medical professionals suggest moms and dads speak with their kids’ pediatricians.
“Because of our training to treat children and teens, many of us are comfortable diagnosing and treating anxiety and depression in kids,” said Joannie Yeh, a Media, Pennsylvania pediatrician. “It can help. Because, I know: Those psychiatrist waiting lists are long.”